Prior Authorization Representative - Oncology

Overview

JOB SUMMARY: 

The Prior Authorization Representative - Oncology is responsible for all aspects involved in obtaining highly complex authorizations and predeterminations for a multitude of In-patient and Out-patient Oncology Services prior to treatment. The Prior Authorization Representative must be knowledgeable and have a thorough understanding of Commercial and Government payers with regards to Coordination of Benefits, Authorization guidelines, Pharmacy and Medical Benefit variances, as well as Medical Necessity Policies. The Prior Authorization Representative is responsible for reading and interpreting various complex medical records to obtain authorizations for requested services and treatment plans. Communication with clinic staff, providers, pharmacists, and insurance companies is essential to ensure completed peer reviews, relay updated medical and specialty drug policies, and appeals. Review reimbursement and denials to ensure all denials and/or contractual adjustments have been reviewed and assess opportunities for retro-active authorizations/appeals and determine root cause analysis.

EDUCATION/EXPERIENCE: 

Bachelor’s degree or 3 years of experience.  

Experience working in health system, medical office, insurance industry or equivalent preferred. 

Prior authorization, Coding and/or Oncology Services experience preferred. 

ESSENTIAL FUNCTIONS: 

1. Assess time sensitive work queues to obtain highly complex authorizations including IP/OP Chemotherapy, Radiology, specifically related to Oncology treatment plans, IP/OP Surgeries, Molecular and Genetic Laboratory Testing.
2. Documents prior authorization activities appropriately and communicates necessary information to providers, care team and third party payers. 
3. Interpret medical records to determine initial and disease progression to prove medical necessity for ordered services and complete on-line clinical requests for advance authorization.
4. Review and/or edit ICD, CPT, and HCPCS codes that substantiate provider’s professional services for ambulatory health records including ambulatory visits and procedures, maintaining established departmental accuracy and productivity standards.
5. Works closely with denial team to provide documentation for appeal. 
6. Review and address monthly denials for Chemotherapy Drugs, Molecular Labs and surgeries with payers and Denial Management Teams. 
7. Reviews all department reimbursements (professional and hospital) to ensure that contractual adjustments and denials are appropriate and have been appealed when necessary. 
8. Reviews for denial trends so adjustments may be made when appropriate by coding staff.

SKILLS & QUALIFICATIONS:

Excellent interpersonal skills and ability to establish strong working relationships with contacts inside and outside the Medical Center

Strong oral and written communication skills to effectively interact with leadership team, patients, physicians and care team on a daily basis

Strong time management skills are required to prioritize assignments and meet pre-determined deadlines

Ability to anticipate, recognize and meet the needs of patients and their families while showing respect and sensitivity for their individual needs

Ability to use initiative, judgement, and discretion in daily work

Analytical skills

Microsoft Word and/or Excel skills

WORK ENVIRONMENT:

Clean, comfortable, office environment

Subject to varying and unpredictable situations

Subject to many interruptions and stressful situations